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About the Author

Bart Knols
Medical Entomologist (Dodewaard, Netherlands)

Bart G.J. Knols (1965) is the Managing Director of MalariaWorld, the world's first scientific and social network for malaria professionals. He is a malariologist with a Masters degree in Biology and a PhD in Medical Entomology from Wageningen University, the Netherlands. He also obtained an MBA degree from the Open University (UK) in 2006, for which he won the prestigious international ‘MBA Student of the Year 2007 Award’ as well as the Alumnus of the Year Award from the Open University. With 11 years of working experience in Africa he has managed large-scale research and vector control programmes on malaria for ministries, international or national research institutions. He has worked for the UN (IAEA) as a programme manager for three years, has served as a consultant for the World Health Organization, and is currently a Board Member of the UBS Optimus Foundation, the second largest charity in Switzerland. He has published over 130 peer-reviewed research articles, has written 16 book chapters, and has served as senior editor on a WHO/IAEA sponsored book on implementation research. In 2007 he co-edited a best-selling book titled 'Emerging Pests and Vector-Borne Diseases in Europe'. He received an Ig Nobel Prize (2006), an IAEA Special Service Award (2006), and in 2007 he became a laureate of the Eijkman medal (the highest award in the field of tropical medicine in the Netherlands). He has been a member of the Royal Dutch Academy of Arts and Sciences since 2004. Bart held an Assistant Professorship at Wageningen University until April '09 with projects across Africa. He currently directs K&S Consulting, a firm he founded in the beginning of 2007.

Post

‘Twitter nets’: Can social media impact disease control?

Published 30th March 2010 - 35 comments - 19847 views -

"It's consciousness-raising and movement building 2.0", said Arianna Huffington, co-founder and editor-in-chief of the Huffington Post. She went a step further by saying "...the goal of eradicating deaths from malaria by 2015 is smart, forward-thinking, and, given the growing reach of social platforms, very pragmatic". These words went along with the UN's start of a social media campaign that was launched on 15 March. Today, two weeks later, many more than 28 million people have heard about malaria from high-profile individuals. That’s impressive.

 

But what is the impact of all this? Tweets are nice but won't save lives, right? Following on from my previous post 'Malaria: When sudden beats chronic', I decided to dig a little deeper below the surface of the impact of news and reporting about malaria.

"Health for all by 2000"

It is June 1995. As I walk through the corridors of the St. Francis hospital in Ifakara, southern Tanzania, I see a beautiful poster with a picture of our planet, taken from space, taped to the wall in one of the wards. Above it the text "Health for all by 2000". A slogan that was masterminded in WHO's headquarters in Geneva, thousands of miles away. But I don't see any health around me. Ifakara had been struck recently by a devastating cholera epidemic, and without the necessary oral rehydration solutions available, people were dying like flies all around me. Army tents were erected outside the hospital to deal with the stream of patients coming in from just about everywhere in the district. In the malaria ward I then witnessed a shocking scene. I saw a wooden box, with eight babies lying in it, all in a row. Each of them had a needle stuck into their heads as a means to connect them to a drip with quinine. Their arms were simply too thin to stick a needle into. Six of them would not survive the vicious attack by malaria parasites. As the year progressed, the poster in the ward started fading, and eventually it fell off and nothing more than a piece of tape, left behind on the wall, reminded me of the "Health for all by 2000" campaign.

But that didn't matter. In Geneva a new initiative was on its way: The Roll Back Malaria initiative. It was launched in 1998. Followed by the Global Fund for HIV/AIDS, TB and Malaria, and then the Millennium Development Goals. And then the Grand Challenges in Global Health initiative of the Bill and Melinda Gates Foundation. On an ever bigger scale we aim to fight the diseases affecting the poorest on the planet. And as time progressed, advertising and marketing specialists got involved. The messages became more gripping, the websites more flashy. Malaria became a business in itself, an industry.

Bednets

Today, more than 800 million people live in countries where formerly they ran the risk of contracting malaria. Europe, Russia, Australia, Taiwan, the USA. This is because shortly after WWII, two powerful weapons to combat malaria became widely available: the miracle drug chloroquine and the miracle insecticide DDT. The combined power of these weapons resulted in a total collapse of disease transmission and ultimately eradication in the aforementioned countries. Patients could be cured, mosquitoes could be killed. Cheap, effectively, and easily. The WHO launched its global malaria eradication campaign in 1955, with the aim, well, to eradicate malaria from the face of the planet. But by 1969 it was all over. Malaria parasites had become resistant to the miracle drug. Mosquitoes were no longer affected by the miracle insecticide. Africa missed the boat. In fact, it had never been a major player in the global eradication campaign. Two decades followed where nothing much happened. Malaria came back, and conquered new terrain. Millions died, but no longer in the North. Malaria had become a disease of impoverished countries, the developing world.

child sleeping under bednetIn the early 1980s, in West Africa, a French scientist named Phillipe Ranque, undertook an experiment that would have an incredible impact on the way we control malaria today. A few years earlier, the Chinese had succeeded in synthesising pyrethroid insecticides. These had become widely available for agricultural pest control, and Ranque decided to study the effect of impregnating a bednet with these chemicals on mosquitoes. Not only were mosquitoes killed when contacting the net in pursuit of the person sleeping under it, the pyrethroid also repelled them. This meant that even torn nets, or holed ones, gave protection.

Large-scale trials with impregnated nets in the 1990s, the first of which was conducted in The Gambia, yielded astonishing results. Mortality dropped by 63% in the group of Gambian kids sleeping under the nets. WHO-sponsored trials in Burkina Faso, Ghana, Kenya, and Tanzania, fuelled optimism. A new weapon against malaria entered the public health arena. The insecticide-treated bednet.

Small message, small donation, big impact

Bednet manufacturers starting making overtime. When I talked to Torben Vestergaard, former Director of the Vestergaard-Frandsen company, back in 2005, he told me that net production had increased ten-fold that year, from 1,8 to 18 million nets.

Dr. Gerhard Hesse, Head of Global Vector Control at the Bayer company, informed me last week that by 2009, some 192 million nets had found their way into African households. Pledges for another 103 million have been secured and hopefully these nets will be in use by the end of 2010. Universal coverage of vulnerable groups (children <5 yrs of age and pregnant women) will require 350 million nets in total, so we're still 55 million nets short of target.

Most of these nets have been funded by large organisations like UNICEF, the Global Fund, and the US President's malaria initiative. But a weapon this small in size and cost did not go unnoticed by the public at large. Numerous small-scale initiatives have been undertaken in recent years, by schools, churches, sports clubs, women’s groups, and so on. Considering that the cost of a net is only 4 €, this is a contribution many in the developed world can afford. Raise money, divide the amount by 4 (€), and here is the number of African children receiving protection from a deadly disease. This weapon is simple, tangible, and can be ‘sold’ to the masses with a one-liner. Perfect.

It is no surprise that NGO’s that jumped on raising public funds for bednets, like ‘Nothing but nets’, ‘Malaria No More’, and ‘Against Malaria’, mushroomed. ‘Save a life for 4€’ is the perfect slogan. Nets sell well.

Last night I watched a documentary ‘When the night comes’ that will be launched the end of April. It was sent to us for previewing and for us to write an editorial on our platform MalariaWorld. The story is gripping. A Ugandan boy, Ivan, dies of malaria in front of the camera. I have seen much suffering in Africa, but this made me swallow once again. It ends with nets. Nets to protect, nets to alleviate suffering, nets that bring happy faces. Nets, nets, nets.

Twitter

Can it be concluded, therefore, that short and simple messages that ask for small sums of money work? Moreover, can it work via Twitter? The answer is…

 


Category: Health | Tags: africa, malaria, twitter, thnk3,


Comments

  • Daniel Nylin Nilsson on 30th March 2010:

    Is there any risk that mosquitoes can get resistant to the pesticides used in the nets? And are there not any health risks for a person sleeping under it? Does preventing malaria with nets mean that the individuals need to sleep under nets during an entire life, or is it for a shorter period?

    Haha, it sounds like I am interrogating, but I am just curious. Unfortunately I am not a malariologist smile


  • Sylwia Presley on 30th March 2010:

    It’s a brilliant action! Thank you for sharing!


  • Bart Knols on 31st March 2010:

    Daniel. Your curiosity is highly justified. As far as human health is concerned, the pyrethroid mostly used on nets is permethrin. This has no mammalian toxicity - no need to worry about that. But when it gets to resistance, yes, there is a really big problem there. You are running ahead lof my story, and I will write a full blog on this topic soon. As for life-long use, well, children get infected with malaria anyway, even if they use nets. Sitting outside in the evening will result in infections. However, use of nets does reduce the number of episodes (malaria attacks) a child suffers annually, and does indeed reduce the severeness and likelihood of dying from it. But, it is of course not the end-solution, a tool with which to eradicate malaria. Again, you’re going to fast, as I intend to write about this also soon. Good points - thanks!


  • Bart Knols on 31st March 2010:

    @Sylwia. Thanks, it is indeed a brilliant action. Others deserve to be mentioned also. The story of former businessman Rob Mather (UK) for instance. Rob watched a TV programme about a young girl that was severely burnt. The medical care and many operations she needed could not be afforded by her parents. Rob, a fanatic swimmer, organised a fund-raising swim with some friends. They raised all the money needed. After that, Mather wanted something bigger. He turned to malaria, and started ‘Swim against malaria’. He has had more than 300,000 people around the world swimming to raise funds for nets. By now, the ‘against malaria’ initiative has almost raised 1,3 million nets…


  • Sylwia Presley on 31st March 2010:

    Very impressive!


  • Maria Kuecken on 31st March 2010:

    This is really interesting, Bart!  Thanks for bringing it to our attention(and also for your history of malaria control).

    I was at a seminar where the presenter said in passing that because bednets can repel mosquitoes (as you mentioned), when there is a certain threshold of nets in one village or area, the mosquitoes leave altogether since it is difficult to find anyone to prey on. Do you know if this is true and/or if there has been any research on that?


  • Bart Knols on 31st March 2010:

    It is indeed true that if coverage reaches a certain level (ca. 80%, or 4 out of 5 people sleeping under a net) that population level effects kick in, and that the mosquito population declines. Various research efforts have demonstrated this across Africa. So boosting the uptake of nets is important. There is one big ‘but’ though. It won’t eradicate the disease, and as Daniel pointed out, this means endless use of nets. Although the mosquito (vector) population will reduce in size, it will remain present in small numbers. When new nets are not provided when the old onesare beyond repair, the problem will return. Alas, this is yet another topic I will write about. Thanks to all for raising these issues. They fuel my thoughts for new blogs…


  • Daniel on 31st March 2010:

    Thanks for the follow up information smile I look forward to reading more postson this topic.


  • Bart Knols on 31st March 2010:

    Thanks Daniel - I need more interrogation-like questions from you all. I have been in the field of malaria for 20 years, and fresh views and opinions stimulate the mind…


  • Bart Knols on 01st April 2010:

    The success of the twitter campaign is becoming replicated, see: http://www.betterplace.org/projects/3436-1000-mosquito-nets-for-uganda-tweet-a-net


  • Maria Kuecken on 01st April 2010:

    Thanks for clearing that up for me, Bart.  I’m looking forward to learning more!


  • Bart Knols on 01st April 2010:

    Hello Maria. If you or anybody else knows of other twitter or social media campaigns that are directly related to the MDGs, that would be great to know. Thanks.


  • Hieke van der Vaart on 05th April 2010:

    Hi Bart, a bit off topic, but the UN itself also campaigns via twitter, this time about Anne Frank:

    http://twitter.com/UNandHolocaust

    http://www.un.org/holocaustremembrance/

    (how can i embed links into my comment by the way?)


  • Jodi Bush on 05th April 2010:

    Very interesting. It’s easy to overlook the simple actions that can be taken amongst all the complexities involved with poverty and disease.


  • Daniel on 05th April 2010:

    @Hieke Thanks for the link! You can embedd links using html coding like this:

    #THE WORD(S) YOU WANT TO LINK HERE

    (The # must not be there, in order for the tag to work)

    The comments accept some html tages, I don’t know exactly whcih and which not.


  • Daniel on 05th April 2010:

    Opa… that didn’t go too well..


    a href=“http://www.un.org”>The UN</a

    (Now, to make the text above link the the UN, simply put a < at the start and a > at the end. smile Everything withing < ... > is basically interpreted as an HTML tag )

    The comments accept some html tages, I don’t know exactly whcih and which not.


  • Iris Cecilia Gonzales on 10th April 2010:

    thanks for this Bart. Informative. Makes one reflect about technology these days. Really fast. They’re helpful in raising awareness, that’s my take.


  • Bart Knols on 10th April 2010:

    Hi Iris. Thanks for commenting. I would love to see other examples of where social media was used to raise funds… do you have any, or anyone else?


  • James Wilson, M.D. on 11th April 2010:

    On 1/12/2010 at 10:19:57 PM UTC (26 minutes after the event), the Praecipio International Intercept Team received a Red Alert from GDACS regarding a 7.3M earthquake in Haiti.  We immediately activated operational biosurveillance support activities and stood the watch as volunteers.

    We were able to rapidly conduct a “radar sweep” using the Internet and by monitoring Twitter feeds across 6 languages for the island of Hispaniola, which includes the countries of Haiti and Dominican Republic.  We knew instantly from media, blogs, and SMS traffic what was being documented in terms of infectious disease.  Consultation with peer-reviewed academic literature enabled us to construct a baseline for several diseases of concern and issue the first infectious disease forecast report in the world, for Haiti, on January 17, 2010. 

    We are practitioners of a new professional discipline called operational biosurveillance.  More akin to disaster sociology than public health, we monitor social indicators of infectious disease crises and disasters.  After 12 years, nearly a quarter million events, more than 250 pathogens, and nearly every country on earth including Antarctica, we have become tuned to the pulse of the planet.  We are the same team that provided warning of the 2009 H1N1 pandemic.

    It has always been our dream to model our discipline after weather forecasters.  On January 17th, we achieved this dream, and since then have produced multiple forecasts designed to flag potential infectious disease crises that could inundate and collapse the very fragile medical infrastructure in Haiti’s quake-affected areas. 

    After the January 17th report, we planned a ground deployment to Port-au-Prince.  From a cold start at the airport on Day 1, we made contact with Sean Penn, Ban Ki Moon (the UN Secretary General), and the contact person for every major NGO and relevant Haitian Ministry within 10 days.  We were able to develop a complete ground verification assessment within a week.  One week after returning, we had signed up over 150 individuals, including Haitian medical providers, into a Google group that became the hub for community-based reporting of disease events as well as training we provide to them in our discipline.  We also created a Geochat SMS group to support emergency communications.  InSTEDD, a Google-funded non-profit organization, developed Geochat.

    In two weeks, Haiti became the first country in the world with a National Weather Service-like infectious disease forecasting center, the Haiti Epidemic Advisory System (HEAS).

    The HEAS has analyzed over 90,000 SMS text messages, thousands of media articles and blog entries, and processed dozens of direct observation ground reports from HEAS reporters in Port-au-Prince.  Events such as suspect outbreaks of meningitis, measles, malaria, and diarrhea have been reported.  Perhaps the greatest achievement of the HEAS was to see the major NGOs forward-position medical countermeasures based on HEAS advisories stating we are at a maximum level of risk now for a pediatric diarrheal disease crisis.  A couple of days ago we posted an advisory for malaria because of one the reporting partners reported a substantial increase in malaria (falciparum) prevalence since the quake. 

    This is the first time in history we are aware of where a National Weather Service-like disease forecasting system drove activation of preparedness measures to save lives.

    Presently, we are at a state of maximum alert.  But our team is without funding and cannot continue the HEAS without it.  This situation represents an emergency, and we urgently need to redeploy to Port-au-Prince to

    •  Continue stockpiling medical countermeasures in preparation for potential crisis conditions;
    •  Expand the informal contact network to support tactical early warning and situational awareness; and
    •  Deploy Intercept Teams to provide rapid response support, rapidly evaluate events of interest, and forward information back to the Ministry of Health

    The future is promising for Haiti if we aggressively seize the opportunity to teach Haitians a new discipline that is rooted in rumor surveillance behavior that is as old as humanity.  Haiti can be the first country in the world to anticipate and proactively intervene outbreaks and epidemics and serve as a model for the rest of the world.  But now we have a crisis on our hands and do not want to sit by powerless as children die from infectious disease.  Now we have an opportunity to act decisively for the love of Haiti.

    Sincerely,

    James M. Wilson V, M.D.

    Executive Director, Praecipio International
    Haiti Epidemic Advisory System (HEAS)
    EMERGENCY APPEAL-
    http://praecipiointernational.org/?page_id=516
    Petionville-Port au Prince, Haiti
    +1.571.225.3671
    Email: .(JavaScript must be enabled to view this email address)
    Skype: iceaxe5
    Twitter: iceaxe5, biosurveillance


  • Iris Cecilia Gonzales on 11th April 2010:

    hi Bart. Yes, I would love to see or hear about that too but I’m not aware of similar examples.


  • Bart Knols on 11th April 2010:

    @James Wilson. This is an impressive development, and it is outrageous that you are without funding to develop this further. Millions, millions of dollars were raised after Haiti, there are fights behind the scenes who is getting what, whereas useful tools like the one you have developed don’t reach the forefront. This is very sad indeed. From here I can just hope that your activities, thanks to TH!NK3 will get broader attention with hopefully funding to sustain your efforts. Keep up the good work.

    As for malaria: This would be THE chance for Haiti to eradicate it. Together with the Dominican Republic… I’ll write about that soon.


  • James Wilson, M.D. on 11th April 2010:

    Hi Bart,
    Yes indeed.  What the HEAS does is get very public and international visibility for malaria because it becomes associated with an actual alert.  Not unlike a storm warning that is part of the daily life down there.  The other intriguing thing a warning system does is hold people accountable- if action is not taken when an alert is issued, and people die because of it, then you can imagine the social outcry.  So, for Haiti, this kind of accountability built into the fabric of society ensures such issues remain foremost in people’s minds.

    Indeed you should see the email transcripts passed between the major NGOs- they are sitting on hundreds of millions, we are asking for less than 1M for a nationwide system.  And they are pointedly ignoring the opportunity.
    It is way beyond time to make this a reality for Haiti.


  • Bart Knols on 11th April 2010:

    @James Wilson. Sadly large NGOs remain oblivious to the new approaches and technologies available to improve health care in disaster-stricken parts of the world. We experience the same problem. We do what every funding agency wants these days: empower scientists in developing countries, improve south-south collaboration, etc., but to extract even small amounts of funding is hard. If you show them that you do what they want, it is still not good enough, and politics kick in. Very sad indeed. Hang in there - perseverence pays off…


  • James Wilson, M.D. on 12th April 2010:

    Bart,
    Agree… we certainly hope to not be on the sidelines as children die in Haiti.  That will be an appalling scenario for all involved.
    Cheers,
    Jim


  • Bart Knols on 13th April 2010:

    @James. The approach we take now is to collect data to demonstrate the power of what you have. Small proof-of-principles, so that you can prove the value of what you have to offer. Would something like that work for your work in Haiti?


  • Wouter Dijkstra on 26th April 2010:

    The Global Fund to Fight Malaria has disbursed $54 million to Uganda. But in August 2005, the auditing firm Pricewaterhouse Coopers concluded that the whereabouts of much of the money was unknown.

    No one knows the exact amount that is missing, but estimates range in the tens of millions of dollars. According to the Pricewaterhouse report and to local newspaper accounts, some of the money ended up in the private bank accounts of government officials. Some was spent on campaign junkets and bogus trips abroad to meetings and “workshops.” Some may have been spent on the campaign to lift presidential term limits so that Ugandan President Yoweri Museveni could enable himself to rule the country untill his heart finally stops beating.

    My question to you is: If it takes an accounting firm like pricewaterhouse Coopers much effort to signal the loss of tens of millions of dollars, how can you be sure that money and bednets from small scale and relatively naive twitter groups reach the right people?

    You must renember that hese people are very smart and experienced when it comes to embezzling money and goods.

    Wouter
    http://www.ict4accountability.wordpress.com


  • Bart Knols on 26th April 2010:

    @Wouter. I cannot answer your question - regretfully. It is simply not possible to track how much money Twitter campaigns raise, nor is it possible to determine how much is actually reaching the field. Even the video of MalariaNoMore under this blog, which talks of 90 thousand nets for Senegal, can not give you confidence that there wasn’t much more funding collected and could have purchased more nets… Do you have a suggestion for how this can be done better?


  • Wouter Dijkstra on 01st May 2010:

    @Bart, I have been doing research on the use of ICT’s in Uganda and the way they can enable permanent monitoring and permanent campaigning for more accountability. Citizens should be involved in monitoring processes. For this purpose media-infrastructure could be set up to facilitate a platforms for these people to help in checking whether funds or goods reach the right people. My posts on this blog will revolve around these issues.. Do you know how “malaria no more” is trying to maximize their impact and keeping nets and money out of the wrong hands? 
    Wouter
    http://www.ict4accountability.wordpress.com


  • Wouter Dijkstra on 02nd May 2010:

    @Bart, I have been doing research on the use of ICT’s in Uganda and the way they can enable permanent monitoring and permanent campaigning for more accountability. Citizens should be involved in monitoring processes. For this purpose media-infrastructure could be set up to facilitate a platforms for these people to help in checking whether funds or goods reach the right people. My posts on ict4accountability on this blog will revolve around these issues.. Do you know how “malaria no more” is trying to maximize their impact and keeping nets and money out of the wrong hands? 
    Wouter


  • Bart Knols on 02nd May 2010:

    @Wouter. Accountability is, I agree, a critical issue. I am planning to set up a skype interview with Scott Case, the CEO of MalariaNoMore USA, and will certainly touch on this point. That’s the best I can do for now.

    Meanwhile, I am getting more worried about reports like that in the LA Times: http://www.latimes.com/news/opinion/commentary/la-oe-shah-20100502,0,85181.story

    Beyond accountability, actual use of nets is a great concern…


  • Wouter Dijkstra on 02nd May 2010:

    @Bart. You are right, I also saw them using bed nets in Uganda to fish. People are stubborn and (understandably) skeptical about the white-mans suggestions on how they should live their lives. I agree that people better come up with their own solutions. Maybe they will eventually come up with the idea for impregnated bed nets.. Still you need local agency and African leadership to convince the people on the ground.


  • Bart Knols on 02nd May 2010:

    @Wouter. I think I have a different opinion on this. Mobile telephones were not developed in Africa, were they? Now look at the uptake of this technology. The point is that as long as a product or process is needs-driven, then uptake will follow. You don’t need to convince people about mobile telephones - there is a clear market-pull mechanism in place. This is not so for nets under certain conditions and cultural settings, requiring a market-push to generate interest and uptake…right?


  • Wouter Dijkstra on 02nd May 2010:

    @Bart. But don’t you think that if there is consensus on the cause and effect of malaria within the African debate, the need for bednets among the population will grow?


  • Bart Knols on 03rd May 2010:

    @Wouter. Maybe so. The point is that if I go out on the street in the Netherlands and ask people what causes Hepatitis A or Q-fever, that 95% of them will have no idea…

    That’s the same for malaria, and logically, awareness then becomes an issue. And maybe this will increase the uptake of bednet technology…

    But even if you use a net, you can get malaria. By sitting out in the evening, or getting up early in the morning. So you tell people that it protects them (which it does but not 100%) and then they get malaria. As a consequence they give up. See the article in the LA Times referred to above.

    Malaria is a deadly disease. Imagine Europe with malaria. We would not use community awareness and nets if it would (still) be endemic here. We would mobilise funding and resources to wipe it out, once and for all.

    But when it gets to Africa, we’re good at lining up arguments why the same can’t work over there. Viola, the root cause of the malaria problem in Africa - lack of will and resources.

    When in 1997 the then Director General of the National Institute for Medical Research (NIMR) in Dar es Salaam, Dr. Andrew Kitua, announced that we could eradicate malaria, he was ridiculed by ‘the establishment’ in the audience. That same ‘establishment’ drafted the malaria eradication plans in 2009… see my point?


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